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Gender Variability, Transsexuals, Crossdressers, and Others (2007)

Gender Variability, Transsexuals, Crossdressers, and Others (2007)

©2007 by Dallas Denny, Jamison Green, & Sandra S. Cole

Source: Denny, Dallas, Green, Jamison, & Cole, Sandra S. (2007). Gender variability: transsexuals, crossdressers, and others. In A.F. Owens & M.S. Tepper, Sexual Health, Vol. 4: State-of-the-art treatments and research, pp. 153-187. Westport, CT: Praeger.

This draft differs in small ways from the printed version. I was unable to scan the printed pages without breaking the book’s spine. The chapter appears here courtesy of Praeger Publishers.



Gender Variability

Transsexuals, Crossdressers, and Others

By Dallas Denny, Jamison Green, & Sandra Cole


In the Western world, gender variance has long been associated and confused with sexual orientation. Gender variance occurs in human beings when a male-bodied individual expresses or displays, consciously or unconsciously, a preponderance of characteristics that are typically associated with femaleness or femininity, and the reverse for a female-bodied individual. Feminine-appearing men have long been thought to be homosexual, and it has been a common misperception that masculine women are “trying” or generally “wanting” to be men so they might legitimately demonstrate their erotic attraction to women. These stereotypes have long plagued homosexual, lesbian, bisexual, transsexual and transgendered people.

Gender identity is a person’s concept of herself as masculine or feminine; gender expression is the gender-based characteristics that a person displays as part of his outward social interactions. There is no direct correlation between gender identity and sexual orientation. There are gay men who are very masculine, lesbians who are very feminine, bisexual people who are not confused about who they are or to whom they are attracted, and transgendered people who are heterosexual (and bisexual, and homosexual).

The classic notion of a transsexual is “a man in a dress,” and there seems to be a general sense that transgender is the new, politically correct word for transsexual. This is a narrow, oversimplified view. There is so much more to gender variance. If we are to understand gender variance and how it differs from and compliments human sexuality, we must clarify what transgender means, and particularly what it means to be transsexual or transgendered in the modern world.


Understanding Gender Variance

In the early 1990s, “transgender” arose from the grassroots as an umbrella term to refer to all types of individuals whose gender identities or presentations differed from binary male/female norms (Green & Brinkin, 1994). The term quickly gained popularity, appearing in both the gay and mainstream press. Today, the term has become ubiquitous and many people who might once have called themselves transsexuals, crossdressers, or drag queens proclaim themselves “transgenders” (see Lev, 2004, pp. 6-7, Taylor & Rupp, 2004).(Endnote 1)

Bornstein (1994, p. 141) considers transgender shorthand for “transgressively gendered.” In fact, many, and perhaps most human beings find themselves in conflict with gender rules at some times in their life. When Shannon Faulkner enrolled at CharlestonS.C.’s all-male Citadel academy in 1993, she made history (Bennett-Haigney, 1995). So did Los Angeles Rams defensive lineman Rosie Greer, when he took up needlepoint in the 1970s (Beller, 2006). The very definitions of what is “right and appropriate” for men and women to wear, how they groom themselves, and their roles in society have changed dramatically over the past several centuries (and even before that) as a result of individuals who, like Faulkner and Grier, have refused to abide by and have rebelled against society’s rules of gender. Trousers, which are now everyday attire for most North American women, were illegal womens’ wear in some states less than 100 years ago (cf Atlanta Constitution, February 26, 1911, p. C7, 2 February, 1913, p. 10B).

As with any other class of people, gender-variant individuals are as a group quite diverse. Transsexual people are those who either have a psychological sense of themselves, or simply desire to live, as members of the non-natal sex (see Benjamin, 1966). Many, and perhaps most, transsexuals lack the finances, social support, or sheer nerve to live publicly as members of the other sex, and they remain in their natal sex throughout their lives. Others seek professional help, with a goal of altering their bodies with hormones, surgeries, and, often for those vectoring toward female, electrolysis, so they may publicly live in the non-natal gender role; this is called “sex reassignment” (Green & Money, 1969), or, in the vernacular, a “sex change.” Yet others manage this obstacle course without any help from, and often in spite of, mental health professionals (see Richards & Ames, 1983, for an example of an obstructive psychoanalyst).

Most transgendered people do not in fact identify as transsexual. They may dress in a gender-neutral manner, blend elements of male and female clothing styles, or dress wholly or partially, full- or part-time in clothing ordinarily worn by members of the non-natal gender. Some modify their bodies in the same ways as do transsexuals, but don’t necessarily seek genital surgery or consider themselves to be members of the non-natal sex (Boswell, 1991, Feinberg, 1992)(Endnote 2). Some individuals (often heterosexual) identify as crossdressers, and yet others as drag queens or drag kings. Increasingly, nontranssexual transgendered people have come to describe themselves as having characteristics of both sexes, as blending genders, or as inhabiting “third-gender,” “transgenderist,” or “genderqueer” space (see Bornstein, 1994; Bolin, 1994; Boyd, 2003; Devor, 1989; Nataf, 1996; Nestle, et al., 2002; Norbury & Richardson, 1994; Rothblatt, 1994).

The reasons for bending or breaking society’s laws of gender display and identity are many and varied. Many men and some women crossdress for erotic reasons; they find it sexually stimulating (Prince, 1978). Some of these men and women may crossdress only once or twice; for others, it is a lifetime interest or, in come cases, obsession (Docter, 1988, pp. 10-19).

Many heterosexual male crossdressers report that over the years, the erotic component of wearing the clothing of the non-natal sex fades away as a feeling of comfort and belongingness grows (Prince, 1978). Many crossdressers give considerable thought to sex reassignment, and more than a few will eventually describe themselves as transsexual (Docter, 1988).

Transsexuals crossdress in order to make manifest their internal views of themselves; to them, wearing the clothing of the non-natal sex is congruent —normal and ordinary. Many transsexuals report having never felt comfortable in the clothing they were “supposed” to wear (see Green, 1994, pp. 1-25).

Most transsexuals report no or minimal history of erotic crossdressing, but a minority of male-to-female transsexuals have recently claimed eroticism as a primary motivator of their sex reassignment (see Allison, 1998, and Lawrence, 1998 for opposing points of view). One sensationalistic writer has denied that male-to-female transsexuals change genders because they identify as members of the non-natal sex; he has claimed on the basis of interviews with transsexuals in night clubs that all male-to-female transsexuals are sexually motivated (Bailey, 2002) (Endnote 3).

There are many other motivations for crossdressing. Some are external. Many natal males and an increasing number of natal females use drag personas in order to provide entertainment, often as a livelihood (cf Norbury & Richardson, 1994; Troka, et al., 2003). Crossdressing can also help to attract sexual partners: drag queens get lots of attention; and oftentimes, transgendered prostitutes find they can make more money when dressed as a woman than as a man (cf Denny, 2006; Rodriguez-Madera and Toro Alfonso, 2005, p. 117). Bisexual or homosexual male crossdressers tend to prefer being in the female role when having sex with men (cf Novic, 2005, Morgan, 1973). Yet another external reason for crossdressing is rehearsal: as an eligibility requirement for genital sex reassignment surgery, transsexuals must dress and live 24 hours a day as a member of the non-natal sex (Meyer, et al., 2001).

By far, however, most reasons for crossdressing are internal, having to do with expressing an inner sense of masculinity or femininity. Crossdressing—even temporarily—can reduce stress by providing an escape from the financial and social pressures of the natal gender role, or, for transsexuals, reduce the dissonance of living in a non-preferred gender role, providing relief and increasing self-confidence (see Brown & Rounsley, 1996, pp. 61-62).

Most transgendered people report developing feelings of differentness and a conscious realization of transgender feelings or identity from early childhood (Brown & Rounsley, 1996, chapter 2). A significant percentage describe an awakening or intensifying of transgender feelings or crossdressing at puberty. Some individuals repress their feelings for most of their lives, often waiting until middle age to begin experimenting with crossdressing or looking into the possibility of sex reassignment. There may a number of reasons for this delay: internal shame and guilt about being transgendered, fear of rejection by their families, fear of loss of employment or social standing, religious convictions, or a concern that they may not “pass” convincingly as a member of the non-natal sex.

The past decade has seen larger numbers of young people coming out as transgendered. This may be an effect of increased visibility of not only transgendered persons, but gay men and lesbians in the media and in real life settings. When transgendered people recognize that they are not isolated and alone, they often feel encouraged to reveal themselves earlier than they might have if they never had seen another person who seemed to feel the same way.


Historical and Cross-Cultural Manifestations of Gender Variance

Examination of the anthropological and medical literature shows that historically, gender-variant people have been common (though frequently repressed by political or religious powers) throughout recorded history, and are present in tribal societies on six continents and many inhabited islands (see Bullough & Bullough, 1993; Feinberg, 1996; Taylor, 1996).

Most non-Western societies have traditionally viewed their transgendered and transsexual members as normal variants of the human condition. Hundreds of tribal societies have socially sanctioned roles for their gender-variant members; indeed, some tribes view those who fit and fill these roles with a combination of awe, respect, and apprehension, often considering them to have special insight, wisdom, and powers, including the ability to view life from “both sides” (Herdt, 1994; Roscoe, 1988, 1990; Williams, 1986). Indeed, cross-cultural research has shown that gender-variant people tend to fill important social roles as educators, shamans, healers, storytellers, and entertainers (Whitam, 1997).

When tribal customs and worldviews are influenced by and diminished by the customs and mores of North American and European societies with their rigid binary constructions of gender, traditional tribal roles for gender-variant people tend to be diluted or supplanted with modern Western sexual identity constructions like homosexuality (Jackson, 1999; Roscoe, 1998, Chapter 8, Williams, 1986, p. 210); it should be noted, however, that in Native North American tribes, the belief by the white scientific community that transgender traditions have disappeared in some tribes may have been largely an effect of tribal members learning not to talk to anthropologists (see Williams, 1986, Chapter 9). Nonetheless, mainstream cultural influences can result in shame of or contempt for gender-variant people who were once accepted and acceptable in their native cultures. Today, there is a movement afoot to reclaim traditional gender-variant identities in Native American communities (cf Jacobs, 1997; Roscoe, 1998; Williams, 1986, Chapter 10).

The patriarchal religious belief systems that attempted to rigidly control sexual behavior tended to confuse gender variance with sexual degeneracy (see Chapter 4, Volume 3 by Stayton). These regimes cast transgendered people from their previous incarnations as valuable tribal members and religious leaders, proclaiming them sinners and driving them largely underground. Nonetheless, there have been a variety of high-profile gender-variant people in Western history, including kings, queens, authors of note, and, arguably, one pope whose femaleness was not discovered until she gave birth during a Papal procession (cf Ackroyd, 1979; Bullough & Bullough, 1993; Dekker & Van de pol, 1989; and Feinberg, 1996; for biographies and autobiographies of representative individuals, see such works as Bullough & Bullough, 1993; Cromwell, 1999; De Eraso, 1996; Derova, 1988; Feinberg, 1996; and Kates, 1995).

Deriving perspective from Judeo-Christian social beliefs, early sexologists turned their attention to gender variance and issues of sexual orientation in the late 1800s (see Irvine, 1990, for a history). Sexual orientation and gender variance were at first conflated by these early social scientists; for instance, Karl Uhlrichs believed homosexuality to be the result of a blend of male and female emotions and feelings, a “hermaphaphroditism of the mind.” (Ulrichs, 1994). Patients we would today consider transgendered or homosexual were called “urnings” or “sexual inverts” (Ellis & Symonds, 1897; Ulrichs, 1994).

Sexologists Havelock Ellis and Magnus Hirschfeld differentiated gender identity from sexual orientation in the early twentieth century, but as Vern Bullough has pointed out, Hirschfeld’s work was unfortunately not translated into English until 1991, and so had minimal impact in the United States (Bullough, 1991, pp. 11-14; Ellis, 1906; Hirschfeld, 1910; Meyerowitz, 2002, pp. 14-15). Hirschfeld’s Berlin Institute for Sexual Research and magnificent sexological library, which contained many case studies of people we might today call crossdressers or transsexuals, was destroyed by Nazis on May 6, 1933 (Rudacille, 2005, p. 49).

In the United States, homosexuality and gender variance have been historically confused and conflated. Early and mid-twentieth century stereotypes of gay men and lesbians tended to be of, respectively, effeminate males and masculine women (Van, et al., 1996, pp. 16-17); in fact, Radclyffe Hall’s prototypical “lesbian” novel of 1928, The Well of Loneliness, is a classic description of a female-to-male transgendered person. Hall’s protagonist even uses the name Stephen.

Social beliefs about homosexuality have changed in recent decades, not because of new scientific knowledge, but as a result of the gay rights movement that coalesced after the Stonewall Riots in 1969 (Clendinen & Nagourney, 1999; Duberman 1993). Post-Stonewall, many gay men and women have come to reject, respectively, stereotypes of effeminacy and manishness in favor of more-or-less conventional models of masculinity and femininity (Dahir, 2006; for a portrayal of contemporary homosexual masculinity, see director Ang Lee’s Oscar-winning 2005 film “Brokeback Mountain”; for a portrayal of contemporary lesbian femininity, see “The L Word” on Showtime cable television). Of course, feminine males and masculine females continue to be found in gay and lesbian communities, but most gay men are conventionally masculine in dress and demeanor, and seek “straight-acting, straight-looking” men as sexual partners (see the personal ads in almost any major metropolitan alternative newspaper, such as the San Francisco Bay Times). With the rise of feminist consciousness, “butchness” fell out of favor in the lesbian community, until “rediscovered” in the early 1990s (cf Burana, et al., 1994; Feinberg, 1993; Munt, 1998; Nestle, 1992).

Before the early sexologists began to pay attention to gender and sexual minorities, gender-variant individuals tended to be viewed by the general public, when they were thought of at all, as sinful or wicked or degenerate. As a result of the writings of sexologists like Krafft-Ebing (1894), gender-variant people began to seen as mentally ill, as “patients” with “conditions” which could hopefully—at least someday—be cured by medical treatments. This set the stage for an unfortunate dynamic when transsexualism came dramatically to the attention of the press, the general public, and the scientific world.


The Mental Illness Model of Transsexualism

In December, 1952, news media around the world trumpeted the news that George Jorgensen, an American ex-G.I. from the Bronx, had undergone medical treatments in Denmark which had changed his secondary sex characteristics and genitals from male toward female; George had become Christine (Hamburger, et al., 1953a). This news was so sensational it bounced coverage of the new H-bomb from the front page (Stryker, 2001; Jorgensen, 1967, p. 144). Until her death in 1989, Jorgensen was such a celebrity that her every move was tracked by the media (Denny, 1998).

While Jorgensen’s was not the first modern “sex change,” (Endnote 4) the media coverage and publications by her treatment team in psychiatric and medical journals provoked immediate negative responses from the psychiatric community, which labeled her, among other things, masochistic, neurotic, psychotic, and a pervert, and her treatment “collusion with delusion” and “collaboration with psychosis” (c.f. Ostrow, 1953; Meerloo, 1967; Wiedeman, 1953). These criticisms were predicated on the belief that Jorgensen’s desire to be a woman was a form of mental illness, at worst a psychotic condition, and at best a delusion. Surely, psychiatrists argued, it was inappropriate and unethical to treat Jorgensen—a person with a mental illness—with hormones or surgery rather than with psychotherapy and psychotropic medications to help her “accept” or “adjust to” her male body.

Psychiatric opinion notwithstanding, Jorgensen’s story inspired hundreds of gender-variant individuals who had had no idea what to do about their feelings to write to her and to members of her treatment team, pleading for a “sex change” (see Hamburger, et al., 1953b). This demand directly led to the formation of the gender identity clinic at Johns Hopkins University in 1966.


The Pathology-Based Medical Treatment Model of Transsexualism

The medical treatment model which arose in the 1950s and 1960s did not dispute the putative mental illness of transsexuals. Indeed, their supposed mental illness provided the medical rationale for the hormonal and surgical reassignment of sex from the natal gender to the non-natal gender. The proponents of sex reassignment:

argued, reasonably, that since no other treatment had been shown effective, sex reassignment should be considered —but only in the most serious and persistent cases: “… my principal argument was that we doctors should be as conservative as possible in advising sex-reassignment surgery or in performing such an irrevocable operation…” (Benjamin, 1966, p. 6) (Endnote 5).

The treatment model that arose took for granted that a wish to deviate from traditional male and female norms—and especially to go so far as to desire to become a member of the non-natal sex—was a form of mental illness. The only treatment offered (or even conceivable under the norms of the day) was to facilitate migration from a traditional male or female body and gender role to the best approximation of the non-natal sex that could be produced with the most modern medical and psychological techniques available (Endnote 6). Sex reassignment was to be used but rarely, and only for the most profoundly “gender dysphoric” (Fisk, 1974), those who were so mismatched in their natal gender role as to be nonfunctional and so profoundly unhappy as to be suicidal, or at least potentially so (Denny, 1992).

Sex reassignment was not considered a cure, but a palliative treatment: since medical interventions (including hormonal therapy, electroconvulsive shock, behavior modification, psychotherapy, psychoanalysis, and even brain surgery) had been tried and proven ineffective in “curing” transsexuals—that is, altering their stated desires to change their sex—the best medicine had to offer was reassignment of sex to make transsexuals feel more comfortable in their bodies. Sex reassignment was accomplished by hormonal therapy and a palette of surgical procedures, along with social reorientation as a member of the “new” sex.

The “syndrome of transsexualism” and the resulting rationale for treatment by sex reassignment was formalized in North America in the 1960s by Harry Benjamin, a pioneering endocrinologist who ultimately treated thousands of transsexuals in his offices in New York City and San Francisco. A veritable handbook for treatment appeared in 1969, edited by Richard Green, M.D. and John Money, Ph.D. of Johns Hopkins University (see especially Green’s 1969 summary). This text described the multidisciplinary approach to sex reassignment used by the gender identity clinic that had opened at Johns Hopkins. This interdisciplinary regimen included psychometric evaluation, group, individual, and family counseling, hormonal therapy, electrolysis (for those vectoring toward female), speech therapy, coaching in dress and behavior, legal assistance, religious counseling, and job placement.

The Johns Hopkins text championed a technique called the real-life test (now the real life experience, or RLE), a requirement that an individual live and work (or go to school) 24 hours a day while dressed as and behaving as a member of the non-natal sex. Only after one year of real-life test could the individual be considered for genital sex reassignment surgery. This requirement had been pioneered by Benjamin, who believed it was crucial that transsexuals have a clear understanding of what it would be like to live as a member of the non-natal sex before undergoing irreversible genital surgery. The Real-Life Test was eventually formalized in 1979 in the first edition of Standards of Care published by the Harry Benjamin International Gender Dysphoria Association, Inc., a professional organization which was dedicated to sharing scientific knowledge and promoting advancements in transsexual treatment.

The gender identity clinic at Johns Hopkins served as a model for other treatment centers which arose across the U.S. and Canada to meet the demand for sex reassignment (Denny, 1992; Meyerowitz, 2002, pp. 7-8). In the 1970s, as many as 40 gender clinics could be found in the United States; most were attached to university medical school hospitals (Denny, 1992). Professionals at these clinics followed the mental illness model of transsexualism and the treatment model developed at Johns Hopkins. Personnel at many of these clinics contributed to the psychological and medical literature of transsexualism by publishing case studies, papers on etiology, demographics, incidence and prevalence, outcomes, and description of surgical and other treatment techniques. This emerging literature posed important questions and generated data which helped to refine treatment techniques and clinic procedures.

The gender identity clinics had far more applicants than they were equipped to treat. Most applicants were rejected as “transvestites” or gay men and offered at best therapy to help them make it through life as a member of their natal gender (Denny, 1992). The few who were accepted were required to meet stringent and sometimes draconian intake guidelines and sometimes required to submit to often-humiliating and arbitrary requirements which demanded lifestyle and relationship changes (Endnote 7). Among the requirements by various clinics were adoption of a sex-stereotyped manner of dress and appearance (literally along John Wayne/Marilyn Monroe lines); absence of physical or mental health problems, possession of a clean legal record, dissolution of legally valid marriages; and changes of job, name, and residence. The medical literature of the day describes lifestyle “suggestions” (cf Clemmensen, 1990). Transsexuals tend to remember it differently.

Clinic patients were encouraged (that is, often required) to break legal and social ties from their former lives in order to live stealthily in the new gender role. Clients were sometimes given assignments to create fictitious life histories consistent with the newly-assigned gender. Even today, thousands of men and women who had sex reassignment in the 1960s and 1970s live in deep stealth (Endnote 8).

Not surprisingly, clinic applicants, through the grapevine, learned to dress and present themselves according to the expectations of clinic staff and to give personal histories of internal conflict and distress which were consistent with the expectations of the staff of the clinics (Stone, 1991). Also not surprisingly, the literature generated by the clinics depicted transsexuals in limited ways, as was consistent with the beliefs of clinic personnel and as was consistent with the characteristics of the subject population—those who had met the clinics’ admission criteria. Transsexuals were depicted in the literature as having stereotyped notions of masculinity and femininity and as having various disorders of behavior, personality, and character (Denny, 1992; cf Stone, 1977). This literature also engaged in something missing from other psychological and medical literatures—name-calling and belittling of clinic applicants (Denny, 2004). The fact that clinic patients tended to read up on their condition was even suggested (albeit tongue-in-cheek) to be part of the syndrome of transsexualism (Money & Primrose, 1968).

Sociologists and anthropologists of the day recognized the disparity in the doctor/patient power dynamic inherent in the pathology-based medical model which was followed by the clinics (see Bolin, 1988, Kessler & McKenna, 1978), but most staff of the clinics ignored these observations and criticisms of non-medical scientists—their books never even made it into review in the medical and psychiatric journals read by the followers of the medical model. Transsexuals might have pointed out the shortcomings of the clinics also, but until the 1990s, transsexuals—who, in the past fifteen or so years, have had a surprising amount to say in print—were unable to contribute to the literature. Their published writings were limited to autobiographies and newsletters. This was not because they chose not to publish, but because they could not get their writings into print (Denny, 1995). Even nontranssexual professionals have found themselves blocked from publishing papers that questioned the wisdom of the medical model; their viewpoints could even brand them as transsexual (and hence, unpublishable) by reviewers (Anne Bolin, personal communication, 2002).

This North American medical and mental health treatment system suddenly collapsed in 1979, with the publication of an outcome study which purported to show “no objective advantage” to sex reassignment surgery in male-to-female transsexuals (Meyer & Reter, 1979). This study, published by two Johns Hopkins gender identity clinic personnel (Endnote 9) in the prestigious Archives of General Psychiatry, was timed for release when John Money, the principal advocate and one of the founders of the Johns Hopkins program, was out of the U.S., and was coincident with press releases and a surprisingly effective publicity campaign designed to generate media coverage showing that sex reassignment “didn’t work” (Lothstein, 1982; Ogas, 1994).

The Meyer & Reter “research” findings were in stark contrast to all other outcome studies. The new study was immediately and strongly criticized on methodological grounds both by Meyer’s peers and from the transgender community (cf Fleming, et al., 1980; Oppenheim, 1979; see also Blanchard & Sheridan, 1990 and Ogas, 1994) and was subsequently proven, by preponderance of evidence, if not beyond a shadow of a doubt, to have been orchestrated by Johns Hopkins Chair of Psychiatry Paul McHugh, who, in a 1992 article in American Scholar, stated that one of his reasons for accepting the Johns Hopkins position was to shut down the gender identity program.

McHugh was successful; the Johns Hopkins program closed shortly after the publication of Meyer & Reter. Within a year or two, most of the other gender identity programs in the United States had closed or had become private providers (Denny, 1992).

While the closing of the gender clinics was initially disastrous for transsexuals, it was, in retrospect, perhaps the best thing that could have happened for transsexualism, for in the absence of the clinics, a free market economy of sex reassignment arose and seeds were sown which led to the availability of mental health services, hormonal therapy, and plastic surgeries from private practitioners unrelated to academic institutions and to the development of the transgender model which has competed with and largely superseded the pathology-based medical treatment model, and which has made sex reassignment the decision of the individual rather than that of the admissions board of a gender identity clinic. Without the clinics as a place for intake, transsexuals in search of sex reassignment began to communicate with one another and to build networks of service providers who were interested not only in providing professional care to gender-variant people, but in learning from their lived experiences. By the early 1990s, with the availability of the internet, there was a flourishing community of conferences, support groups, national advocacy organizations, and local and national centers for referrals and dissemination of information. This community includes hundreds of helping professionals consisting of, but not limited to, psychiatrists, psychologists, clinical, social workers, licensed professional counselors, family and marital therapists, sexologists, plastic surgeons, endocrinologists, urologists, gynecologists, speech and language therapists, electrologists, and cosmetologists; there are also hundreds of vendors, who market everything from elevator shoes, breast binders, and urinary assistance devices for female-to-male transsexuals to oversized jewelry, breast implants, hip pads, and large-sized shoes for male-to-female transsexuals.

By the mid-1990s, this emerging community was highly organized and informed and was pushing hard for legal reform and reforms of treatment.


The Transgender Model

The pathology-based medical model followed by the clinics was surgically-based. Applicants who failed to demonstrate a clear, unambiguous, and fervent desire for genital surgery were simply not admitted for treatment, and were usually not even followed up (cf Stone, 1977). Transsexuals themselves believed that to be “properly” transsexual, they had to desire this surgery with the utmost urgency. This situation began to change in the early 1990s, with the 1991 publication of a paper by Holly Boswell and a 1992 booklet by Leslie Feinberg. Boswell and Feinberg further developed a concept first described by Prince (1973), who declared it legitimate to inhabit gender middle ground, living full-time in non-natal or third gender roles without the necessity of surgery or even hormones (Bolin, 1994) (Endnote 10). This eventually revolutionized not only the ways in which gender-variant people characterized themselves, but the ways in which they were depicted in the popular press.

The new transgender model broke with the pathology-based medical model, depicting transsexuals and other gender-variant individuals not as mentally ill, but as displaying a natural form of human variability, one that is present in all societies and throughout history. The transgender model has had a profound impact in a short time. It has generated a new lexicon, naming not only a community, but providing an identity for those individuals who consider themselves different from either transsexuals or crossdressers. It has provided a model that presumes that gender-variant people are essentially healthy beings, and a treatment rationale that does not require migration from one gender stereotype to another. It has offered an unlimited number of individualized paths that gender-variant people can take and divorced them from the socially-imposed necessity of having genital surgery, while maintaining genital surgery as an option. It has refocused the presumed pathology away from gender-variant people onto an unforgiving society which rejects and mistreats them (see Boswell, 1997; Devor, 1996). And perhaps most importantly, it has questioned the appropriateness and healthiness of rigid binary gender norms and provided alternative ways for both transgendered and nontransgendered people to live their lives (Bolin, 1994; Boswell, 1997).

Certainly, American and other societies have shown and continue to show strong evidence of their intolerance toward gender-variant people (see the Remembering Our Dead website at <>. Thousands of transsexuals and other transgendered people are attacked and beaten every year, and dozens are murdered every year simply for being perceived as “different.” Many other forms of discrimination abound. Gender-variant people are routinely subjected to police harassment, arrest, and imprisonment merely for being themselves. They are routinely denied public accommodation and denied access to shelters, and frequently find themselves in grave danger simply by being in public, even when doing their best to blend in. They are often turned out of their homes by families which denounce and disinherit them (See Green & Brinkin, 1994; Wilchins, et al., 1997). Many gender-variant people have great difficulty in the job marketplace because of discrimination (Walworth, 1998a; 1998b), and some who are prevented from working are forced to turn to sex work or other illegal activities in order to support themselves. Local, state, and national legislation denies them rights allowed to other citizens (Currah, Minter, & Green, 2000). We end this paper with a discussion of the burgeoning transgender rights movement which has arisen as a direct result of this societal mistreatment.


Medical and Mental Health Issues


HBIGDA and the Standards of Care

By the 1960s, surgeons and other professionals with an interest in treating gender-variant individuals were attending conferences on gender identity issues. In 1979, these professionals formalized their relationship, forming the Harry Benjamin International Gender Dysphoria Association. In 1979, HBIGDA published Standards of Care for Hormonal and Surgical Sex Reassignment, which are updated periodically (see Meyer et al., 2001, for the latest revision). The Standards are minimal consensual guidelines developed by HBIGDA members for the hormonal and surgical treatment of transsexual and other transgendered people. The Standards recommend repeated sessions with mental health professionals; resulting letters of authorization recommend clients’ access to hormonal therapy and surgical sex reassignment procedures. These letters are presented by the clients to their physicians and surgeons. The Standards further recommend the completion of a one-year real-life experience before genital surgery is performed.

Ongoing revisions of the Standards of Care reflect changes in philosophy and new knowledge about gender identity issues. The Standards serve a valuable purpose in that they are designed to protect both those seeking medical procedures and those who provide them. However, they are unique in that they impose restrictions on therapies for gender-variant people that other classes of people do not have. Nontransgendered people can often obtain the same technologies (hormonal therapy and plastic and cosmetic surgical procedures) with no special restrictions imposed upon them.

While most helping professionals, and for that matter most transsexuals see some value in placing restrictions on access to medical treatment, in their twenty-five years of existence, the HBIGDA Standards of Care have generated no data to either support or question their effectiveness (Endnote 11). They are supported only by the clinical judgment of the members of HBIGDA— and the organization’s members are not of a single mind about the Standards. After more than 25 years, transsexual and other transgendered people are placed in the unique and unenviable position of being required to follow guidelines which restrict their access to medical care, despite the lack of objective and conclusive evidence that the guidelines are effective.



The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its text-revised fourth edition, is the primary nosological sourcebook of the mental health field. In 1980 DSM introduced gender variance into the third edition—coincidentally, the edition in which homosexuality was removed as a mental disorder (Endnote 12). Transsexualism and Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (the latter added in the 1987 revision), were listed under the heading “Disorders Usually First Evident in Infancy, Childhood, or Adolescence,” as was Gender Identity Disorder of Childhood. Transvestic Fetishism was included under the heading “Sexual Disorders.”

This changed with 1994’s DSM IV. Transvestic Fetishism was moved to the category “Paraphilias,” and Transsexualism was dropped. Gender Identity Disorder was subsumed under the category “Sexual and Gender Identity Disorders.” Gender Identity Disorder of Childhood was introduced in DSM IV, also under the “Sexual and Gender Identity Disorders” category.

There has been a great deal of debate about the inclusion of gender identity disorders in the DSM, and there have been calls for removal or reform (cf Wilson, 1998, 2000; Wilson & Hammond). Criticisms have included the sexism that permeates the DSM, the DSM’s rigid delineation of sex roles, and the use of prejudicial language. Critics have noted that while DSM diagnosis saddles the gender-variant diagnosee with the stigma of mental illness, the corresponding social and financial benefits of mental illness are often denied. For instance, although insurance companies require a diagnostic code before they will pay for treatment, most insurers specifically deny reimbursement for expenses related to sex reassignment. Also, transgendered people are specifically excluded from the Americans with Disabilities Act of 1990.

Without a doubt, the most problematic DSM category is Gender Identity Disorder of Childhood. Activists have long considered this category a back-door re-introduction of homosexuality, as its diagnostic criteria fit many pre-homosexual men and women (Vasey, 2000). GID of Childhood has provided a means of forcing involuntary incarceration of children and adolescents for the purpose of “converting” them into heterosexuals; for a graphic description of this, see Scholinsky, 1996.

Transgendered people are themselves divided about the issue of inclusion in the DSM. Some seek reform, some seek removal, and some hope that more insurance companies will one day reimburse transgender-related expenditures, for which they expect a diagnosis of some kind will be required (Endnote 13).


Mental Health Issues

The simple fact of being gender-variant can impose tremendous stress on an individual; this can come both from within and from external sources.

Most transgendered and transsexual people report having experienced intense negative emotions related to their feelings and behaviors; these include fear, shame, guilt, and anxiety. Their gender-variant behaviors and desires may be ego dystonic, causing them to hide and deny them and become overcome with shame and guilt. Many gender-variant people eventually overcome these negative feelings by a coming out process analogous to that of gay men and lesbians, but many more struggle with negative or ego-dystonic emotions all of their lives; Lev (2004) calls the process of growth and acceptance “Transgender Emergence.”

Hiding or denying transgender feelings can result in a constellation of self-destructive behaviors. These can include withdrawal from daily activities or attempts to self-medicate with tobacco, alcohol, and other drugs (Tayleur, 1994). Sometimes the individual will compensate by engaging in hypermasculine or hyperfeminine behavior. Natal females may marry, bear children, find jobs which have been historically considered the province of females, and do their best to fulfill societal stereotypes of femininity (cf Kailey, 2005). Males may marry and father children, build up their bodies with exercise, join street gangs, tattoo themselves, enlist in the military, or seek hypermasculine careers (see Brown, 1988). Many seek and fulfill leadership roles in their communities. Both males and females may engage in extreme sports and other high-risk behaviors. Suicide attempts, body cutting, genital self-mutilation, and sexual acting out, including promiscuity and unprotected sex, are common (cf Beatty, 1993; Farmer, 1994).

Those who have come to terms with their inner natures are much less likely to engage in such behaviors. Even after such balance is reached, however, individuals who have struggled for years in inner turmoil may bear psychic scars which manifest as residual chronic depression, dissociative disorders, or other diagnosable mental conditions. Additionally, they must live with histories which may include poor or nonexistent work history, poor coping skills, substance abuse, criminal records, and the burden of a long history of secrets, unpleasant memories, and fear of discovery.

It should be noted that while most gender-variant people struggle with these issues, many are mentally healthy (Lev, 2004). The transgender community abounds with individuals who have excelled in all aspects of their lives.



Most gender-variant people report having been bullied, and many report having survived physical attacks (Wilchins, et al., 1997). Rejection by parents, siblings, extended family members, friends, and sexual partners is common, and teachers, church and government officials, law enforcement, and medical personnel are often nonsupportive or actively hostile (cf Green, 1969). Many gender-variant youth are turned out of their homes and must support themselves on the street (see Our trans children, 2004). Transgendered adults are often shunned or bullied on the street, harassed in their jobs and neighborhoods, and expelled from churches and social organizations.

Social ostracism and ridicule is not limited to those who transition gender roles. The very differentness of gender-variant people often provokes ridicule, harassment, or attack. This reactive negative behavior is often imposed on family members and friends of gender-variant people as well. Even being perceived as gender-variant can be fatal. On July 29, 2001, Willie Houston, a nontransgendered heterosexual man, was shot to death at OprylandPark in Nashville, Tennessee. The reason: he was carrying his girlfriend’s purse and escorting a blind friend to the mens’ room (see Examples of hate crimes against transgender individuals.)

Many gender-variant people report histories of extended sexual or physical abuse; this can lead to dissociative disorders, post-traumatic stress syndrome, and other disorders (see Cole et al., 2000, pp. 170-171). Under the pathology-based medical model, it was assumed that any co-existing mental condition was part and parcel of the “syndrome” of transsexualism. While mental illnesses can certainly co-occur with gender-variant behavior, it should be noted that such disorders are frequently sequelae of abuse related to the stigma and disenfranchisement of being transgendered rather than part of the gender identity issue per se (Lev, 2005, p. 203).



All human beings manifest sexual behavior, and transgendered and transsexual people are no exception. Unfortunately, observers frequently make unwarranted assumptions about the sexual orientation and behavior of gender-variant people. Perhaps because of a history of mutual struggle for rights, respect, and identity shared by gay men and lesbians and the transgendered, many people presume that gender-variant people are homosexual (as determined by their natal gender role). In fact, some people, despite overwhelming evidence to the contrary, cannot be dissuaded from this opinion (cf Varnell, 1996). One of the most frequent criticisms of transsexualism is that those who seek or undergo sex reassignment are attempting to escape from internalized feelings of homophobia—that is, that they are dealing with their homosexuality by seeking to reconstruct it, by changing sex, as heterosexual. This theory ignores the fact that it makes no sense to “escape” from a stigmatized minority (homosexuality) into a minority that is much more heavily stigmatized (transsexualism). About half of both pre- and non-operative male-to-female transsexuals are sexually attracted exclusively to females (Green, 2004). Many female-to-male transsexuals identity as gay men and live as such after gender-role transition; many others are exclusively sexually oriented towards females.

The issue of sexual orientation of gender-variant individuals is a complex one. Terms such as heterosexuality and homosexuality lose their meaning when cast loose from the moorings on which they are based—femaleness and maleness:

Should homosexuality be considered in relation to the individual’s natal sex, or their new role? Is a transsexual woman who is still fulfilling the role of husband in a marriage in a lesbian relationship? Certainly, it does not seem so to the world, which sees a heterosexual relationship. And yet five years later, when the individual has transitioned into the woman’s role, the same couple, if publicly affectionate, will be perceived as lesbian. What of a post-transition nonoperative transsexual woman in a sexual relationship with a male? The public sees a heterosexual couple, and yet, in the bedroom, their genitals match. Should their sexual act be considered heterosexual or homosexual? Does it matter if the feminized partner does or does not take the active role in intercourse? And what if the same individual then has surgery and finds a female partner? Is this relationship homosexual or heterosexual? Finally, what if a nonoperative transsexual man has as a partner a post-operative transsexual man? Is this a gay relationship? A straight one? Are any of these people bisexual? And most significantly, can the term bisexuality have any meaning at all when gender is deconstructed?

 –Denny & Green, pp. 88-89

Gender-variant people are nonetheless sexual beings who must interpret their own sexual attractions and desires. They may partner with natal males, natal females, or both, or with other transgendered people. They may be abstinent or promiscuous, kinky or “plain vanilla.” They are perhaps the best arbiters of whether their relationships are “heterosexual” or “homosexual” or something else altogether.

Gender-variant individuals do not live in vacuums. They are connected to other human beings through family relationships, marriages, parenting, community, church, school, the workplace, and through their citizenship in cities, states, and nations. When the individual changes gender role, not only the individual, but every individual with whom he or she has a relationship is in some way, great or small, affected.

Those most impacted are family members. It can be devastating to learn that a loved father or mother, sister or brother, or son or daughter, crossdresses or is considering sex reassignment. How does one relate to a co-worker, employer, or employee who will be coming to work with a different gender presentation? What is the church’s position on this? How will you remember to call your bowling partner by his or her new name?

Many gender-variant people are visibly “different” from an early age. They are simply unable or unwilling to suppress or hide their feelings and identity. This can result in hostility to the child by the family (Burke, 1997). Other individuals successfully hide their gender variance from their loved ones.

A decision to change sex later in life may strike others as sudden, capricious, or ill-considered, although it almost never is. The prior secrecy and closeted behavior regarding the transgender identity can reinforce this perception. When a transgendered person’s gender variance becomes known, the family often reacts as if the lack of previous disclosure was intentional and purposefully deceitful. The withholding of information is in truth best recognized as a reflection of the transgendered person’s fear of being abandoned by loved ones. For many families, the discovery of truth can predictably be experienced as a major emotional trauma which may have been triggered by the discovery of a secret cache of clothing, the accidental opening of a letter, or a spontaneous confession. Reaction can be profound, ranging from tearful acceptance to permanent rejection. Under such traumatic emotional conditions, it is essential that the family seek counseling or therapy (see Rosenfeld & Emerson, 1998 for a systems approach to family counseling; see also Lev, 2004).

Clearly, issues of how, when, and from whom the disclosure was made can have a huge impact on the way the revelation or discovery of gender variance is initially received. For example, a wife who has returned home unexpectedly early to find her husband wearing her clothing and makeup can understandably feel traumatized, and can easily be catapulted into extreme feelings of betrayal, fear, and anger (Cole, 1998, 2000).

It is perhaps in the area of family and loving relationships that therapists can be most effective. Reaching out to the family as a whole, each member of which may react to such sudden information and change with shock, fear, or rejection, is undoubtedly therapeutically valuable. Uninformed people presume that because the mother or father in such a family is changing gender roles, it is inevitable that the marriage will dissolve, with custody of minor children going to the nontransgendered parent. However, it is more likely that, with thoughtful clinical intervention and education, the family has a solid opportunity to remain intact (Cole, et al., 2000).

Many marriages endure with the presence of occasional crossdressing. The social and medical life changes imposed upon the family by a member’s sex reassignment, however, can be profound. External supports such as peer support and especially counseling may be essential in helping the family remain intact as they work through gender-role transition. Partners and families can ultimately stay together with love and respect.


Transgender Health Issues

Gender-variant people experience the same constellation of aches, pains, illnesses, and malignancies as do the nontransgendered. Maintaining wellness can be problematic for the transgendered—but there are real health risks which are specific to transgendered people, and they are at increased risk for other health hazards.

Transgendered and transsexual individuals often fear discovery and rejection from health professionals from whom they seek medical assistance; consequently, some tend to avoid visits to healthcare practitioners. Male crossdressers may avoid routine medical checkups because they are self-conscious about shaved legs and chests. Both male-to-female and female-to-male transsexuals may avoid checkups or delay or fail to seek treatment because they are self-conscious about or ashamed of their bodies and the reactions of caregivers. If the individual has transitioned gender roles but has not had genital surgical sex reassignment, he or she may be realistically concerned about a negative reaction from health care providers if and when their genital status is discovered (see Green, 1960). If the individual has not transitioned gender roles and presents for treatment in the natal gender role, he may still be concerned that the physician will somehow be able to determine his transgender status. Those with such fears include not only those who have altered their bodies with hormones, electrolysis, or surgery, but those whose body shape and physical characteristics naturally fall outside the traditional male and female norms.

This avoidance can translate into undiagnosed illnesses. Beyond avoidance, there may be so much dissonance about the body that the individual neglects to properly care for it. Natal females may avoid gynecological examinations and breast exams; natal males may avoid prostate exams. Both may avoid dental care and tests for HIV and other sexually transmitted infections (STIs), and neglect chronic conditions like diabetes, high blood pressure, and heart disease. They may fail to seek treatment to stop smoking or reduce alcohol or drug use (Sperber, et al., 2005).

Gender-variant people face a number of health risks specifically associated with being transgendered (Endnote 14). Female-to-male transsexuals have a higher than usual risk of polycystic ovarian syndrome, an endocrine disorder (Balin, et al., 1993). Gender-variant individuals may have undiagnosed intersex conditions like Klinefelter Syndrome (an XYY chromosomal pattern; cf Davidson, 1966) or congenital adrenal hyperplasia (a virilizing endocrine syndrome; see Erhardt, et al., 1968).

Ingestion or injection of opposite-sex hormones can produce not only the usual risks associated with their use, but pose additional risks such as embolism, especially in the absence of medical monitoring (Cole et al., 2000) (Endnote 15). Female-to-male transsexuals may develop acne following initiation of testosterone therapy and may develop abnormal lipids that can lead to coronary artery disease (Prior & Elliott, 1998). Clearly, it is advisable to have frequent medical monitoring for hormonal tolerance and equilibrium following a laboratory test of blood levels and organ function to create a baseline (Basson & Prior, 1998; Cole, et al., 2000; Prior & Elliott, 1998).

Transsexuals often avail themselves of non-genital plastic surgeries to enhance their internal image of themselves. In male-to-female people, these can include rhinoplasty (nose surgery), laryngioplasty (tracheal shave or reshaping of adam’s apple), surgery to increase vocal pitch, face lifts, brow lifts, hair transplant or relocation, chin and cheek implants, injections of fat cells or collagen, breast implants, liposuction, and shaving of the facial bones to reduce strong male characteristics and cause the individual to more closely resemble the desired female form (see Lynn Conway’s Facial Feminization Surgery Page at Genital surgeries include orchiectomy (castration) and can include penectomy (removal of the penis); these can occur as separate operations, although more frequently they are part of vaginoplasty (surgical creation of a neovagina). Male-to-female transsexuals usually have various forms of electrolysis and laser treatment to remove facial hair. Female-to-male transsexuals often have surgery to remove breast tissue and create a more masculine chest contour, and may have metaoidioplasty (a procedure which modifies the testosterone-enlarged clitoris into a more penis-like erectile organ), phalloplasty (surgical creation of a phallus), fusion of the labia and testicular implants, and (rarely) surgery to masculinize the face. Additionally, FTMs may undergo hysterectomy and oophorectomy (removal of the ovaries) to avoid medical complications. (See Green, 1995 and 2004 for a discussion of FTM surgeries; Hage, 1992, and Schrang, 1998 for discussion of vaginoplasty).

Even when performed by accomplished surgeons, surgical procedures can pose risks to health. When they are performed by inadequately-trained physicians, the results can be devastating. Unfortunately, in their desperation, transgendered people can fall victim to charlatans. After plastic surgeon John Ronald Brown lost his medical license, he continued to do vaginoplasties, often in non-sterile conditions, with usually poor results. Brown continued his “practice” for years, operating out of Tijuana, Mexico, before finally being arrested and sentenced in San Diego for fatally removing a healthy leg from an aged man. (Williams, 1999). Lately, authorities have become aware of and have begun prosecuting unlicensed “practitioners” who engage in the widespread, occasionally fatal practice of injecting non-medical grade liquid silicone into cheekbones, breasts, hips, and just about every other part of the body; this is done in an attempt to gain “instant curves.” (cf Curtis, 2005; see also Silicone use: Illicit, disfiguring, dangerous, 2 July, 2003). Health problems resulting from silicone injection can include disfigurement, respiratory and systemic illnesses, and death. Once injected, silicone cannot be completely removed, and even incomplete removal can lead to further disfigurement.

Gender-variant people are at risk for hepatitis and HIV/AIDS if they share needles for injection of estrogen, testosterone, silicone, or illegal drugs. Many male-to-female gender-variant people make their living as sex workers, often performing (at the request of their clients) sex acts without protective devices like condoms. Studies have shown astonishingly high seropositivity rates among such populations (see Elifson, et al., 1993; see Bockting & Avery, 2005 for recent needs assessments).

Male-to-female transsexuals have been unfairly accused of having a pathological need for multiple surgeries (cf Raymond, 1980). Multiple surgeries are necessary for some MTF individuals in order to achieve a viable presentation in the non-natal gender, which can enhance employability and decrease the risk of discrimination, harassment, and physical attack. Cranial reshaping and facial plastic surgery procedures can make a considerable difference in a person’s appearance and result in a dramatic improvement in way she is treated in public (Alison, 2001). It should be noted, however, that a few transgendered people share with some nontransgendered people an unhealthy need for repetitive surgeries. Similarly, some transgendered people will dress and groom themselves in a conspicuously excessive manner. This is usually an effect of rehearsal, and will disappear with time, but fetishistic individuals may prefer an outrageous or outlandish appearance and some genderqueer-identified people will deliberately dress to give a gender-ambiguous appearance.


Transgender-Caregiver Interactions

In the course of their careers, both mental and physical health professionals are likely to encounter a number of clients with gender identity issues. Although most practitioners understandably choose not to specialize in issues of gender and sexuality, it is nevertheless important that all caregivers be sensitive to the needs of the client and responsible for learning and understanding enough information about the transgender population to provide minimal or palliative care until referral to a more experienced caregiver can be made. It is certainly not appropriate to blindly turn away the transgendered client simply because she is transgendered.

It’s important for caregivers to realize that many of the issues which confront transgendered people are only peripherally related to their gender identity issues, that many of their medical and psychological needs are essentially the same as those of other clients, and that they can almost always be helped by almost any practitioner. The client with gender identity issues should be considered as a whole person, with needs in areas which often don’t require a sex or gender specialist, and should be offered services if the caregiver specializes in the areas of need. Caregivers inexperienced with gender identity issues should be aware of their prejudices and biases, continue to educate themselves about transgender issues, and seek advice and supervision from peers.

The actual gender issue is best handled by a professional with special training and experience in gender identity issues. Unfortunately, practitioners with such training and experience are relatively rare, and nonexistent in some parts of North America.

Some professionals—usually those working within certain religious frameworks—believe that gender variance is a mental illness and that God intended human beings to live in the bodies into which they were born (Endnote 16). They take it as their duty to “protect” such people from themselves by doing whatever they can to dissuade them from accepting their transgender natures and convince them to embrace rigidly heteronormative gender norms. This is usually ineffective, and it is unethical to impose personal values on a client. The responsible professional will, after making certain the client is aware of available treatment options, assist that client to realize his goals.

Even today, few caregivers receive training to work with gender-variant individuals. Many of the most experienced professionals in the field are considered pioneers, as they began their work in a time when there was little available literature and no opportunities for professional training. They typically began their work with transgendered clients with no sources for referral, and no knowledge or supervision, learning from their clients. Learning from clients continues today, often needlessly, as much literature, clinical guidelines, and case history treatment protocols are available and realistically helpful. Many gender-variant people complain that they have paid to educate their therapists about gender identity issues; that is, any number of therapy sessions are taken up by helping the therapist understand about transgender issues. While it once may have been necessary and effective for the therapist to learn specifics of the transgender process from their clients, it is no longer so. Therapists now can consult with peers who already have specialized knowledge about gender variance, subscribe to journals like HBIGDA’s International Journal of Transgenderism, join organizations like HBIGDA, The Society for the Scientific Study of Sexuality, the American Association for Sexuality Educators, Counselors, and Therapists, and can attend training institutes and national and international conferences on transgender issues.



Transgendered people seek therapists for a variety of reasons. First, they have the same needs for therapy as the general population. Secondly, there are unique stresses related to being transgendered. The financial, marital, and social disruption, and the loss and discrimination that accompany gender-role transition place additional pressures on the individual, increasing the usefulness of therapy. And finally, there is the issue of the letters that are needed for initiation of hormonal therapy and genital sex reassignment surgery.

Therapy can center on assisting the transgendered individual to cope with his feelings about choosing to or having to remain in their natal gender role, or, if she is exploring transition, assist her to guide herself through the difficult process of changing her gender role.

A prime responsibility of the therapist is to assist the client in developing a realistic life plan to accommodate the many challenges that lie along the transgender journey. Many gender-variant people don’t fully understand their options. Therapists can and should assist them to understand that they can make a myriad of choices about the ways they will live their lives.

Therapy should be nondirective; the object is not to convince the client to accept a particular outcome, but to enable the client to make a wise choice after considering all of the available options. Unfortunately, there is a long history of abusive relationships between therapists and their transgendered clients (see Bolin, 1988; Kessler & McKenna, 1978). This frequently takes the form of promising and then withholding the necessary authorization letters for hormones and surgery. This dynamic is perhaps unsurprising, considering the power imbalance inherent in the therapy setting and general societal prejudices about transgendered people, but it unfortunately continues.

The therapist should come to an agreement with the client about the goals of therapy, and, if authorization letters are to be written, should reach a negotiated understanding with the client about just what will need to be done by both therapist and client in order for the therapist to write the letters. It is often helpful to formalize this via a written contract.

Regardless of whether the individual is considering transition, it may be necessary to assist him in identifying and negotiating boundaries for expressing his transgender nature that will respect and maintain his marriage, relationships with his family and communities, and employment.

The transgendered client can benefit from referral to peer support organizations. We strongly recommend this, as support groups can provide the individual with model coping strategies and help to build a network of supportive friends. The caregiver can direct the client to literature and make appropriate referrals to other professionals as indicated by the client’s needs. It is of primary importance to include and engage the spouse and other family members in the counseling process.

The time may come when the therapist is asked to write a letter of recommendation to a family doctor, endocrinologist, or plastic surgeon as part of the HBIGDA Standards of Care, for initiation of hormonal therapy or for genital surgery. If, in the judgment of the therapist, the individual has met the guidelines for eligibility and readiness spelled out in the HBIGDA Standards of Care, and if the therapist does not have reality-based concerns about the individual’s welfare if he undergoes such treatment, it is appropriate to write the letter of recommendation.
Wellness-Based Medical Treatment Models

New models of transgender medical treatment are developing which have as an underlying basis the presumptions that transgendered and transsexual people are mentally healthy individuals, and that their gender variance is integral to the healthy people they are. These models provide the same medical treatments as did the earlier pathology-based medical treatment model, but benefit from improved caregiver-client interactions and a lack of the limiting beliefs of the earlier model. Moreover, they are providing new and nonpathologizing language to describe gender-variant people (Cromwell, et al., 2001) and helping to develop a literature that does not unfairly characterize or blame transgendered people for deficiencies in the treatment process (Endnote 17). The new models have caused a profound difference in the professional literature, which now squarely addresses the patient-caregiver dynamics of the treatment process.

These new models take a number of forms. One example is the walk-in clinic. Since 1993, San Francisco’s transgender residents have known that on any Tuesday, they can attend the Tom Waddell Clinic to address acute or chronic mental or physical health problems. They can get prescriptions for hormones and have their blood levels monitored; receive treatment of HIV and STIs; or attend a peer-support group (Sondegaard, 1994; see also

Another model treatment program, the Gender Identity Project at the Gay and Lesbian Community Service Center of New York, is peer-based. The Project offers one-on-one peer counseling and professionally and peer-facilitated groups for women and men of transsexual experience and parents, family and friends of transgendered people, focused on “[assisting] individuals to overcome the shame and guilt associated with gender-based oppression so that each of them can build a life which will promote growth, development, and freedom” (Blumenstein, et al., 1998). GIP participants have access to the Center’s other activities and services, including HIV/AIDS services and groups focused on bereavement and grief, “coming out,” and recovery (p. 429). A liaison with the Community Health Project, which has offices in the Center, resulted in the Transgender Health and Education Clinic, which opened in 1995, providing medical care.

The past decades have seen the reinvention of gender identity clinics in North America (Endnote 18). Following the collapse of the gender clinics in the late 1970s, the Program in Human Sexuality eventually took on the administrative responsibility of the University of Minnesota’s gender program. PHS, which offers a full range of services to transgendered and transsexual people (Endnote 19), took an early lead in exploring non-surgical options and HIV in the transgender population and has been active in HBIGDA and publishing research papers and books on transgender issues.

Since 1993, the University of Michigan Health System Comprehensive Gender Services Program has provided a full range of services to transgendered people and their families. This academic, multidisciplinary program, which includes medical and mental health care, a variety of surgeries, including genital sex reassignment, and allied health services including speech/language therapy and dentistry, focuses on issues of wellness and whole-person health care. The transgendered client/patient is centrally involved as a participant in the decision-making process at all stages of the health care experience (Cole, 1998). This includes identifying and developing realistic life goals, reviewing self-progress, and being fully educated to his own unique health needs. CGSP interacts with campus student health and with the program offerings of the office of Gay, Lesbian, Bisexual, and Transgender Affairs. Transgender community affiliates and organizations comprise the extended services of CGSP; this includes bookstores, welcoming restaurants and entertainment, specialty clothing boutiques, and legal services. The University houses the National Transgender Library & Archive, a large collection which was donated by Gender Education & Advocacy, Inc., a nonprofit with which all three authors are affiliated.

These and other programs provide services in settings which allay many of the fears of their transgendered clients and continue to develop new models of transgender health care which respectfully include the active participation of transgendered people and their families.


Transgender Politics

Before about 1995, transgender organizations were primarily educational in nature. This is hardly surprising, considering that it was almost impossible to find information about crossdressing and transsexualism, and the scant information that could be found tended to sensationalize gender variance or emphasize its negative aspects. This has changed dramatically over the past decade. The formation of an active and vital community, and especially the development of the Internet has resulted in an explosion of information which has focused activism, reached spouses, families, and transgender youth, and enabled transgendered people in rural areas to find support. Now there are transgender political organizations working on local, state and national levels to advocate for the civil rights and social safety of all transgendered people (Endnote 20). In many metropolitan areas, public health advocates have taken on transgender access to health care as both a social and political cause. Working in tandem with gay, lesbian, bisexual, and intersex activists, social progress has been significant. In 1995, only one state (Minnesota) and four cities (Minneapolis, Seattle, Santa Cruz, CA, and San Francisco) had limited anti-discrimination protection for transgendered and transsexual people. Today, nearly one-third of all Americans are protected by their cities, counties, or states against hate crimes or discrimination, or both (Currah, et al., 2000; for an up-to-date listing, see Many colleges now have courses and even programs in gender studies, and new scholars abound. Hundreds of texts have appeared, and gender-variant characters make frequent appearances in books and on the silver and television screens. Movies about transgendered characters have won awards at film festivals like Cannes and Sundance, and even at the Golden Globe and Oscar ceremonies.

In spite of this new visibility, the battle for the legal rights of gender-variant people is hardly over. Opposition– primarily from the radical religious right and conservative activists– is ongoing, highly coordinated, and often venomous. Battles are being conducted daily in every level of the courts, in city halls and in state and federal legislatures, where the civil rights of both gender-variant and gay and lesbian individuals are highly contested: Don’t Ask, Don’t Tell, the right to marriage and domestic partnership, adoption, anti-discrimination and hate crimes bills and ordinances are at issue in jurisdictions across the country. Can a person change her or his sex? Should a person be able to have a legally sanctioned relationship with another person of the same sex, even if one of the parties has changed her or his appearance to that of the opposite sex? Should transgendered people be able to be parents, retain parental rights after a divorce, or adopt children? Should a transsexual person be eligible to serve in the military? Should a military veteran who is also transsexual or otherwise transgendered be eligible for medical treatments through the Veteran’s Administration? What happens to transgendered people if they enter the prison system: are they housed according to the shape of their genitals or according to their gender presentation? All of these questions and more are at issue in the early twenty-first century. But when we understand that transgendered and transsexual people, through their gender variance, are simply experiencing a different relationship to their bodies and genders than nontransgendered people do, it becomes easier to see that they deserve the same rights and accommodations as any other person receives, and they can go on about their lives as do other human beings, with self-esteem, dignity and respect.




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Endnote 1: It should be noted that some transsexuals dislike and disidentify with the term transgender. This is because, having permanently transitioned gender roles, they consider that they have little in common with those who cross gender lines only partially or temporarily (Lev, 2004, p. 6).

Endnote 2: Virginia Prince used the term “transgenderist” to describe those who, like herself, lived permanently in the non-natal role without having or wanting genital sex reassignment surgery (Ekins & King, 2005).

Endnote 3: Many in the transgender community perceive Bailey’s book as an insult. Certainly, Bailey makes broad negative claims without substantiating them. He was investigated by his university (Northwestern) after several of his “research” subjects lodged complaints against him, claiming they were unaware that he was was using them as subjects (Wilson, 2004).

Endnote 4: The first reported “modern” sex reassignment surgery was Abraham (1931); see Cowell, 1954; Dillon, 1946; Hoyer, 1933; and Meyerowitz, 2002 for other examples.

Endnote 5: Perhaps the single most important characteristic of transsexuals, as noted by the medical personnel to whom they turned for treatment, was discomfort—often acute—experienced at being forced to live in bodies that did not correspond to their gender identities. Today’s transsexuals feel the same anguish, but, thanks to the Internet and the wide availability of printed material, have more opportunities to share their feelings with others and develop effective coping strategies than was true in the second half of the twentieth century.

Endnote 6: Indeed, complete reassignment of sex, with plastic surgery to transform the genitals, was the only treatment—aside from remaining in the natal gender—that either medical professionals or the transsexuals of the day seem to have even considered. Only one person—Virginia Prince (1972)—argued for an intermediate path (living in the non-natal gender role without genital surgery). It was nearly twenty years before others echoed Prince’s call (Boswell, 1991; Feinberg, 1992). For a short autobiography, see Prince (1997).

Endnote 7: One transsexual woman has reported being required to engage in homosexual behavior:

“… ‘Alternate lifestyles. Homosexuality.’

“’I’m not homosexual. Nor do I want to be. I want to be a woman.’

“He banged his fist on the table. ‘We’re not here to negotiate! You’ve heard our terms. Take them or leave them.’”

— “Margaux,” in Denny, 1992, p. 15

Endnote 8: Some post-transition transsexuals choose to construct their new lives in such a way that nobody “knows” they are living in the non-natal gender role; see Duncan Tucker’s film “TransAmerica” for an example of this).

Endnote 9: One (Meyer) was the clinic’s director, the other (Reter) a secretary.

Endnote 10: Ekins and King (2005) place Prince’s concept of transgenderism, or non-surgical crossliving, as early as 1968.

Endnote 11: Most social science research is generated in corporate or university environments. Most private practitioners lack the funding, personnel, and equipment necessary to design, conduct, evaluate, and publish research. The scarcity of university-affiliated gender identity programs in North America has resulted in a decrease in research and publication on transgender and transsexual issues.

Endnote 12: Homosexuality was removed as a mental disorder from 1973’s DSM II as the result of considerable discussion and politicking; see Bayer, 1980. The diagnostic category Ego-Dystonic Homosexuality remained in the DSM until 1980.

Endnote 13: See Lev, 2004, Chapter 5, for an excellent discussion of issues of diagnosis.

Endnote 14: See Cole, et al., 2000, for a discussion of health risks facing transgendered people.

Endnote 15: In a misguided effort to hasten masculinization or feminization, some transgendered people take dangerously high dosages of hormones. This can result in severe medical complications or even death. The first author has anecdotally known of several cases in which the medically-monitored initiation of estrogen therapy in natal males was immediately followed by gall bladder disease necessitating surgery. Bolin (1988) reported the death of one individual who was self-administering high dosages of estrogen (Chapter 9).

Endnote 16: Often conveniently forgetting or ignoring the myriad other ways in which we modify our bodies or have them modified.

Endnote 17: See Gorton, et al., 2005; Israel & Tarver, 1998; & Lev, 2005, for excellent examples of this emerging literature.

Endnote 18: Gender clinics survive in many places in the world. Progressive university-affiliated clinics in Netherlands have generated dozens and perhaps hundreds of research studies and developed a treatment model for adolescent transsexuals (Gooren & Delemarre-van Wall, 1996). There are clinics in most other European countries and in many other nations throughout the world.

Endnote 19: The exception is genital sex reassignment surgery, which is not provided on-site, but through referrals, when appropriate.

Endnote 20: Cf (Gender Education & Advocacy); (The International Foundation for Gender Education); and (NationalCenter for Transgender Equality).